Transitions of Care – The Roadmap to Effective Points of Care

February 22, 2023 | Written by: Real Time Medical Systems

During a recent educational series hosted by Health Data Management and KLAS Research, Real Time’s Executive Vice President of Health Systems Solutions Phyllis Wojtusik, RN, and Vice President of Clinical and Network Quality Margie Latrella, MSN, APN-C dissect what an award winning, scalable transitions of care model looks like, helping patients, families, and acute/post-acute teams stay on top of points of care. With CMS’ ongoing initiative of decreasing readmissions and push towards value-based care, now is the time for acute care providers to make care transitions a priority among their post-acute network providers.


The True Costs of Transitions of Care

In only the course of a year, an astonishing $26 billion dollars is spent as a result of poor care transitions between acute and post-acute facilities. Aside from the overwhelming costs, patients are at highest risk of readmission during transitions of care. This risk can be largely attributed to the inconsistent communication between acute and post-acute partners, resulting in gaps in patient care.

Under the best of circumstances, patients may arrive in a less than ideal physiological state during care transitions and if a warm hand off/ nurse-to-nurse communication doesn’t transpire between providers, it’s the patient left with the biggest impact and potential negative outcomes. The impacts of poor care transitions can span the care continuum from acute to post-acute care, as well as from post-acute care back home and to the community. Furthermore, when the receiving care facility is not adequately prepared for a patient admission, including equipment and medications, this only intensifies the risk associated with care transitions.


How to Go from Troubled to Award Winning

Acute care providers, including Accountable Care Organizations (ACOs), can face numerous challenges in trying to achieve successful care transitions and patient outcomes. One of the most significant challenges is the limited day-to-day insight into what is happening with patients, as well as the manual data entry which is often required for documenting and tracking readmissions. With this minimal knowledge, it’s impossible to determine if trends are developing and if there is a change in clinical condition or patient diagnoses. The lack of transparency and accurate, real-time data, hinders the ability to determine which patients are decompensating, making it impossible to intervene prior to a readmission occurring.

Subsequently, with these challenges comes an opportunity to mitigate the lack of transparency of data between care providers. With the aid of post-acute data analytics, acute care partners can view post-acute clinical documentation as it occurs – no matter where the patient is discharged from. It also allows for patient risk stratification to identify and manage high-risk populations and provide facilities the capability to intervene in treatment by monitoring vital signs, diagnoses, and orders. Care providers can additionally utilize discharge reports to connect the patient back to the community for successful transitions. Furthermore, ACOs can receive up-to-the-minute network performance comparisons with uncompromised visibility into clinical data, including readmit rates, length of stay (LOS), and readmission case types. With this data at their fingertips, acute care providers can also identify post-acute issues/barriers and bring their high-performing network together to share best practices in an effort to improve patient outcomes while reducing total cost of care.


Real-World Benefits of Setting up Your Network for Success 

Within the first year of implementing Real Time’s interventional, post-acute data analytics solution, St. Joseph’s Health System, a world-class hospital and healthcare network, was able to realize a post-acute cost savings of $1.6 million dollars. In having a focus on improving patient outcomes in the PAC setting, St. Joseph’s Health identified multiple opportunities to impact quality, total cost of care, and patient satisfaction.

Through the creation of a post-acute nurse navigator role and the implementation of Real Time’s Interventional Analytics solution, St. Joseph’s Health reduced their skilled nursing facility (SNF) readmission rates from 24% to 17.8%. With the ability to monitor patient progress and outcomes at the PAC facility, St. Joseph’s Health was also able to improve care transitions and ensure appropriate LOS in order to return patients back to the community. Most notably, they were also able to scale this solution across all their value-based care programs where similar outcomes have been achieved.

As a result of their efforts, St. Joseph’s Health was recognized with the 2022 NAACOS Leaders in Quality Excellence Award at the 2022 Spring NAACOS Conference. With their partnership with Real Time, St. Joseph’s Health was able to establish a mutually collaborative relationship with the SNFs in their High Performing Network (HPN), resulting in a 43% increase in post-acute network referrals.


Drive Successful Care Transitions & Achieve Cost Savings 

There are multiple principles which drive success within PAC transitions and generate cost savings. A pivotal element is data transparency through obtaining live post-acute documentation. By accessing live patient data from the post-acute EHR, care providers can improve collaboration networkwide.

Additionally, the creation of a HPN can also add significant value to post-acute partners. In utilizing real-time data, care providers can measure PAC performance and lead quarterly network management meetings.  The establishment of a PAC nurse navigation role overseeing the patients in PAC facilities contributes to ongoing success for the both the ACO and post-acute network. By focusing on patients discharged to a PAC setting, care providers can improve clinical outcomes, transitions of care, readmissions, LOS, and patient satisfaction. To learn more about how solutions like Real Time can help improve care transitions, contact us today.


To view the full on-demand webinar session and supportive document, click here.

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